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My counseling was in Manhattan (New
York County), where, in 2010, there was a grand total of 103 private
plans – 33 HMOs (including six without prescription drugs), 8 POSs (including 2 without prescription drugs), 9 PPOs (including 2 without prescription drugs) and
nine PFFSs (including 3 without prescription
drugs). In addition, there are
forty-four special needs plans for persons who are dual eligible for
Medicare and Full Medicaid (31 plans), people in long-term care
facilities (9 plans) and people with certain chronic or disabling
conditions (3 plans) and one demo.
They add up to a grand total of 103 private plans.
I have completed my annual analysis (started in 2005) of
the HMO/PPO “scene.”
Hopefully, the following snapshots (*) will be helpful in making HMO and PPO plan selections
less complicated.
*You should
obtain a current listing of available plans (HMOs may close enrollment
because of capacity limits) from medicare.gov, to insure that you
don’ miss out on any that might be of interest to you. And most importantly, you will have
available an outline of costs and benefits of the individual plans.
*As mentioned
in my introduction, there are Special Needs Medicare Advantage plans
(SNP) for beneficiaries who have full Medicaid, live in institutions or
have chronic or disabling conditions.
Two main questions need to be answered by a Medicare-Medicaid
person considering SNP. Will the
State pay for the cost sharing for Medicare covered services? Will the choice of doctors in the
Medicare Advantage SNP be a better match for his/her needs?
*I found that HMOs and PPOs offer variations in cost sharing and access to
benefits that are difficult to distinguish. The co-insurance billing of costs in
HMOs and PPOs/Network is based on
negotiations with providers. The
costs, of course can vary and you are advised to call the plans for the
details. Therefore, % of cost is
not % of Medicare approved amount.
However, in the case of PPOs/Outside
Network, the co-insurance billing of % of cost is % of Medicare
approved amount. I mistakenly
believed that % of cost in PPOs/Outside
Network had the same meaning as % of cost in HMOs and PPO/Network. The marketing material should have
identified PPO/Outside Network cost as % of Medicare approved amount --
so much to be said for transparency.
*An analysis of
the seven PPOs (with prescription drugs) show
four plans charging 25%/30%/50% of Medicare approved amount to members
who chose to go to outside of network providers. Approximately 74% and more of their
medical services (2 plans-91%, 1 plan-80% and 1 plan-74%) were billed
at % of Medicare approved amount – the remainder at
co-payment. The four PPOs have the following out-of-pocket limits for
outside network providers: $3500, $5000 and two plans @$2500. A second group of three PPOs have more of the favorable co-payment terms
for outside network providers.
Two plans bill 24% of outside of network services at (almost
all) 20% of Medicare approved amount to members going to outside of
network providers and offer out-of-pocket limits of $4000 and $3350. The third of the group of three bill
46% of network services at (almost all) 30% of Medicare approved amount
and has an outside limit of $6800.
*The trend in billing for
outside-of-network services is going back to co-payment – a vote
for transparency. However, the
slope is still slippery.
*The billing of (co-insurance) %
of cost of a service to the insured member continues to be used in HMOs
instead of the usual co-payment.
My count shows 26 HMOs out of 27 using this method – 13
plans for 1 through 3 services, 9 for 4 through 7 services and four
HMOs with 8 through 11 services.
Only one plan did not use the co-insurance method. In 2009, 4 plans did not use the
co-insurance method.
*I discovered in 2007 a new
mystery in HMO cost sharing. A
majority of HMOs stated the following: You may have to pay separate co-pays for certain doctor office
visits. In 2010, the message has
changed to “Separate Office visit cost sharing of $(specific
amount) co-pay may apply.”
Therefore, the uncertainty continues, but to a lesser extent --
48% of HMOs are now participating in this type if billing. This is a vast improvement from prior
years: 75%-2007, 68%-2008 and 59%-2009.
However, uncertainty regarding additional doctor co-pays will
still continue for a significant percentage of HMOs. Let us not forget, that we still have
the regular schedule of in-network co-pays for Medicare-covered visits
for primary care, urgent care and specialists.
The following HMO cost information
needs to be given in tandem:
*Eight of 27 HMOs charge a
monthly premium in 2010, same number of HMOs as in 2009. They are as follows: $98, $61, $40, 2 @ $33.30, $33, $30.60 and $22. And twenty-two HMOs (18 last year)
charge for hospital visits – 1 has hospital stays at $200 and 21
hospitals have co-payment schedules ($10-$200) from 6 days to 10 days.
*Access to
benefits in 2010 is now more clearly defined, because the following rule
was discontinued in seven HMO plans: “Referrals are required for
specialists for certain
benefits.” This rule
caused confusion to beneficiaries in those plans. For example:
*The seven HMO
organizations stated in their plans in 2009: “You must go to
network doctors, specialists and hospitals.” Referral is not required to seeing a
physician specialist.” And
they went on to state the following: “Referrals are required for
specialists for certain benefits.”
*Authorization
for HMO services is playing a greater role in 2010 compared to the
prior years. I submit the
following analysis of the 27 plans each with brackets of 1-3 services
totaling 39 services.
*Minimal authorization (9
plans)-Two plans have no authorization, three plans each with one
authorization covering one service and three plans each with two
authorization covering five services.
*Medium authorization (13 plans)-8 to 13
authorization rules in each plan that apply to eight to eighteen
services.
*High authorization (5 plans)-each
with 15, 15, 15, 16 and 23 rules that apply to 21, 22, 22, 23 and 30
services.
*Therefore, there is the
possibility, that the insurance plan may countermand the order that has
been based on the diagnosis code of your internist or specialist.
*And to top this off, you are
warned in many of the HMO brochures: “The health providers in our
network can change at any time.”
Therefore, I suggest that you check your prospective medical
provider visit with your insurance company for the following: Is the
provider a network provider? Is
a referral needed? Is authorization from the HMO needed?
The total
“picture” cries out for standardization and
transparency. In the meantime
– what can we do? First, focus on the doctor(s) you
are using or will be using.
Go to the plans where those doctors can be found. This will narrow the search for
choice of plan – then examine the provisions very carefully,
keeping in mind the possible
trouble spots. Please remember
that HMOs and PPOs are not the diagnosticians
– doctors are. This is
the counseling advice I have given over the years – it may stop
you from feeling you are searching for health care in a
“commodity exchange.”
I addressed this topic in fuller detail in the previous
segment. And if the search for
the plan is still difficult, seek one-on-one counseling. Medicare segment 09 will offer details.
Updated: March 23, 2010
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